The objective of this pilot study is provide data for planning and to establish the feasibility of performing a large, randomized, comparative effectiveness trial of two specially designed airway tubes (endotracheal tubes;ETTs) for the prevention of ventilator-associated pneumonia (VAP). Modification of the material and design of the ETT cuff that is positioned in the trachea, and/or continuous aspiration of subglottic secretions through an extra port positioned between the tube cuff and the vocal chords may prevent leakage of contaminated secretions around the cuff and thereby reduce the risk of VAP. The investigators are planning a phase III, randomized, controlled trial comparing the effectiveness of a polyurethane-cuffed endotracheal tube (PUC-ETT), a polyurethane-cuffed tube that also allows continuous aspiration of subglottic secretions (PUC-CASS-ETT), and a conventional, polyvinylchloride-cuffed endotracheal tube (PVC-ETT) in mechanically ventilated patients with respiratory failure. Prior to initiating the Phase III trial, a smaller pilot study is necessary in order to establish feasibility and to gather data on endpoints in order to establish enrollment rates and project sample size for the definitive trial. For the purposes of planning, a surrogate for VAP, bacterial colonization of the trachea will be assessed from daily quantitative cultures to allow estimation of effect size for the two study devices. Secondary aims include the determination of whether the placement of these ETTs has beneficial effects on other important clinical endpoints, including ventilator-free days, 28-day mortality, intensive care unit and hospital length of stay, and to determine the safety profile of the devices by assessment of upper airway complications persisting after removal of the ETT. Approximately 90 critically ill patients undergoing emergency tracheal intubation in- or out-of-hospital will be randomized to receive one of the three ETTs. VAP will be diagnosed using objective criteria, based on cultures from bronchoalveolar lavage. The safety profile of the tubes will be evaluated using a multi-faceted approach, including short-term objective measures of laryngeal dysfunction and long-term subjective and objective assessment of upper airway problems via phone interview post-hospital discharge, and recording of device-related adverse events. PUBLIC HEALTH RELEVANCE: This pilot study will provide data for planning and establish the feasibility of performing a definitive comparative effectiveness trial of two modified endotracheal tubes designed to reduce microaspiration of subglottic secretions in reducing the risk of ventilator-associated pneumonia. The study will be performed in a diverse population of critically ill patients with acute respiratory failure, and colonization of the lower airways with bacteria will be used as a surrogate for the risk of ventilator- associated pneumonia. The results from this pilot study will be used to estimate sample size and patient enrollment rates for the larger, Phase III trial.